Clinical Governance Framework | UniSC | University of the Sunshine Coast, Queensland, Australia

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Clinical Governance Framework


USC is committed to providing a range of health services and associated activities of the highest possible standard to ensure that patients and clients receive safe, quality care.

This is the commitment regardless of the service being directly operated by USC or provided by a third party through an arrangement or an agreement initiated by USC.

The USC Clinical Governance Framework supports that commitment by detailing the principles and actions that govern the operation of all USC health services and/of health related services and functions.

USC defines health service and health related services and functions as services that address:

….. the prevention, treatment and management of illness and injury, and the preservation of mental and physical wellbeing through the services offered by clinicians, such as medical, nursing and allied health professionals.

This is the definition of health care in the Australian National Safety and Quality Health Service Standards.

Governance, leadership and culture

The USC Clinical Board assumes governance responsibility for all clinics and health engagement activities undertaken by or associated with USC.

The Clinical Board is committed to supporting and maintaining a culture of quality care and continuous improvement. It will oversee and monitor clinics and health engagement activities to ensure this objective is being met.

Any proposal to create a new clinic or change (including location) of an existing clinic must be approved by the Clinical Board (out of session approval is available if required). In this context the definition of a clinic is “any USC or USC associated Health Clinic and other health related activity”.

The USC Schools that operate clinics or enter into arrangements with third parties, the USC Clinical Trials and the Thompson Institute (TI) are all responsible and accountable for the effective operation of their services and for considering the safety and quality of health care for patients / clients in their decision-making. All USC and USC associated third party Health Clinics and other health related activities are to be formally assessed by the accountable USC organisational unit (responsible School, USC Clinical Trials or TI), at least annually against the requirements of this Framework. Further assessment must occur if there are any material changes to the operation of the service.

All clinics associated with USC and operated by a third party must have in place a formal memorandum of understanding with regard to responsibility for the areas outlined in this governance framework.

Patient safety and quality systems

All clinics and health service engagements operated by or associated with USC will:

  • Operate within a formal documented policy framework that is monitored for compliance.
  • Comply with all legislative and professional registration and associated standards.
  • Identify safety and quality measures and monitor and report performance and outcomes.
  • Proactively pursue continual improvement in safety and quality.
  • Identify and document organisational risks and act to reduce them.
  • Actively participate in the organisation-wide incident management and investigation system.
  • Seek regular feedback from patients / clients and families about their experiences and outcomes of care.
  • Encourage and support patients /carers and families, and those involved with the provision of services to report complaints.
  • Create and manage healthcare records systems that comply with all legislative, regulatory and privacy provisions as well as facilitate safe clinical practice, clinical audit and research.

Clinical performance and effectiveness

All clinics and health service engagements operated by or associated with USC will:

  • Have a defined scope of clinical practice for clinicians, and students.
  • Monitor clinicians’ practices and students’ roles to ensure that they are operating within their designated scope of clinical practice.
  • Provide supervision for students to ensure that they can safely fulfil their designated role.
  • Support the workforce and students to understand and perform their roles and responsibilities for safety and quality.

Safe environment for the delivery of care

All clinics and health service engagements operated by or associated with USC will:

  • Maximise the safety and quality of care through the design of the built environment and by maintaining buildings, plant, equipment, utilities, devices and other infrastructure that are fit for purpose.
  • Provide a welcoming environment that respects all cultures and recognises the importance of the cultural beliefs and practices of Aboriginal and Torres Strait Islander people.

Partnering with consumers

All clinics and health service engagements operated by or associated with USC will:

  • Actively utilise all opportunities to involve patients / clients and their families in the delivery, evaluation and improvement of services.
  • Understand the evidence on consumer engagement, and its contribution to the safety and quality of health care
  • Understand how health literacy might affect the way a consumer gains access to, understands and uses health information



Australian Commission on Safety and Quality in Health Care. National Model Clinical Governance Framework. Sydney: ACSQHC; 2017.

Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service Standards. 2nd ed. Sydney: ACSQHC; 2017.